Arquivo da tag: dysphagia

Dysphagia as a predictor of outcome and transition to palliative care among middle cerebral artery ischemic stroke patients

San Luis CO, Staff I, Fortunato GJ, McCullough LD.

BMC Palliat Care. 2013 May 10;12(1):21

Abstract

BACKGROUND:

Middle Cerebral Artery (MCA) territory strokes can be disabling and may leave patients unable to swallow safely. Decisions regarding artificial nutrition and goals of care often arise in patients with severe strokes leading to dysphagia. This study determined some predictors of early transition to palliative level of care among patients with acute ischemic MCA stroke with dysphagia.

METHODS:

This is a retrospective cohort study. Demographic and clinical data of patients presenting to Hartford Hospital with an acute ischemic stroke between January 2005-December 2010 were gathered utilizing the Stroke Center at Hartford Hospital Database. The 236 patients included were divided into “early transition” and “not transitioned” to palliative care cohorts. Primary outcome was transition to palliative care. Factors that were significantly associated with an early transition to palliative level of care in univariate analysis were then entered into a multivariate logistic regression analysis to identify potential independent predictors of early transition to palliative level of care. The significance level was set at p < 0.05.

RESULTS:

79 patients (34%) were transitioned to palliative level of care after failing the first swallow evaluation within a median of 3 days. Factors predictive of an early transition to palliative level of care after multivariate logistic regression analysis included advancing age (p < 0.001; OR: 1.10; 95% CI :1.056-1.155) , left MCA infarct (p = 0.039; OR: 0.417; 95% CI:0.182-0.956), a high NIHSS score on admission (p = 0.017; OR: 3.038; 95% CI: 1.22-7.555), administration of intra-arterial tPA (p < 0.001; OR: 7.106; 955 CI 2.541-19.873) and the inability to be assessed on the 1st swallow evaluation (p < 0.001; OR 0.053; 95% CI 0.022-0.131).

CONCLUSIONS:

The severity of dysphagia influences early transition to palliative level of care in acute stroke patients. Independent predictors of an early transition to palliative level of care among patients with an acute MCA territory stroke and dysphagia included advancing age, a left MCA infarct, a high NIHSS score on admission, administration of intra-arterial tPA and the inability to be assessed on the 1st swallow evaluation. This information may guide discussions with families of patients with MCA territory strokes regarding artificial nutrition and goals of care.

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Cough reflex testing in Dysphagia following stroke: a randomized controlled trial

 

Miles A, Zeng IS, McLauchlan H, Huckabee ML.

J Clin Med Res. 2013 Jun;5(3):222-33. doi: 10.4021/jocmr1340w. Epub 2013 Apr 23.

Abstract

BACKGROUND:

Significant health issues and service delivery costs are associated with post-stroke pneumonia related to dysphagia. Silent aspiration is known to increase pneumonia and mortality in this population. The utility of cough reflex testing (CRT) for reducing pneumonia in acute stroke patients was the subject of this randomised, controlled trial.

METHODS:

Patients referred for swallowing evaluation (N = 311) were assigned to either 1) a control group receiving standard evaluation or 2) an experimental group receiving standard evaluation with CRT. Participants in the experimental group were administered nebulised citric acid with test results contributing to clinical decisions. Outcomes for both groups were measured by pneumonia rates at 3 months post evaluation and other clinical indices of swallowing management.

RESULTS:

Analysis of the data identified no significant differences between groups in pneumonia rate (P = 0.38) or mortality (P = 0.15). Results of CRT were shown to influence diet recommendations (P < 0.0001) and referrals for instrumental assessment (P < 0.0001).

CONCLUSIONS:

Despite differences in clinical management between groups, the end goal of reducing pneumonia in post stroke dysphagia was not achieved.

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The significance of accumulated oropharyngeal secretions and swallowing frequency in predicting aspiration.

Dysphagia. 1996 Spring;11(2):99-103.

This study retrospectively investigated the value of both endoscopically visible oropharyngeal secretions in the hypopharynx and swallowing frequency in the prediction of aspiration of food and liquid. Fiberoptic endoscopic evaluation of swallowing (FEES) was performed on a total of 69 individuals that included hospitalized elderly, nonhospitalized elderly, and young normal subjects. A four-level rating scale for determining the severity of accumulated oropharyngeal secretions was developed and employed to rate subjects prior to the presentation of food or liquid during the FEES. Spontaneous dry swallows were also counted during the observation period of the FEES. It was found that the accumulation of endoscopically visible oropharyngeal secretions located within the laryngeal vestibule was highly predictive of aspiration of food or liquid. There were significantly fewer spontaneous swallows in hospitalized subjects when compared with nonhospitalized subjects. There was also a significant decrease in the frequency of spontaneous swallows in aspirating hospitalized subjects when compared with nonaspirating hospitalized subjects. Results are discussed in terms of integrating this information with clinical bedside examination techniques.

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The influence of sour taste on Dysphagia in brain injury: blind study

Lee KL, Kim DY, Kim WH, Kim EJ, Lee WS, Hahn SJ, Kang MS, Ahn SY.

Ann Rehabil Med. 2012 Jun;36(3):365-70. doi: 10.5535/arm.2012.36.3.365. Epub 2012 Jun 30.

Abstract

OBJECTIVE:

To verify the influence of sour taste on swallowing and the presence of reflex cough when sour material was swallowed in patients with dysphagia secondary to brain injury.

METHOD:

Fifty dysphagic brain injury patients who underwent videofluoroscopic swallowing study (VFSS) were recruited. The patients who had shown severe aspiration at 2 ml of liquid were excluded. The dysphagic patients were given 5 ml each of a sour tasting liquid (SOUR) and a thin liquid barium (LIQUID) in random order. An expert analyzed the result of VFSS by reviewing recorded videotapes. Analysis components consisted of the Penetration-Aspiration-Scale (PAS) score, oral transit time (OTT), pharyngeal transit time (PTT), pharyngeal delay time (PDT) and the reflex cough presence.

RESULTS:

The PAS score for SOUR was significantly lower than the one for LIQUID (p=0.03). The mean OTT for SOUR was significantly shortened compared to that for LIQUID (p=0.03). The mean PTT and PDT were also shortened in SOUR, although the differences were not statistically significant (p=0.26 and p=0.32, respectively). There was no significant difference between SOUR and LIQUID regarding the presence of reflex cough (p=1.00).

CONCLUSION:

The sour taste could enhance sensorimotor feedback in the oropharynx, thus lowering the chances of penetration-aspiration caused by shortening of the oropharyngeal passage times. There was no significant difference in the presence of reflex cough produced between LIQUID and SOUR.

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The effects of removable denture on swallowing

Son DS, Seong JW, Kim Y, Chee Y, Hwang CH.

Ann Rehabil Med. 2013 Apr;37(2):247-53. doi: 10.5535/arm.2013.37.2.247. Epub 2013 Apr 30.

Abstract

OBJECTIVE:

To investigate the relationship between removable dentures and swallowing and describe risks.

METHODS:

Twenty-four patients with removable dentures who were referred for videofluoroscopic swallowing study (VFSS) were enrolled. We evaluated the change of swallowing function using VFSS before and after the removal of the removable denture. The masticatory performance by Kazunori’s method, sensation of oral cavity by Christian’s method, underlying disease, and National Institutes of Health Stroke Scale for level of consciousness were collected. Functional dysphagia scales, including the oral transit time (OTT), pharyngeal transit time (PTT), percentage of oral residue, percentage of pharyngeal residue, oropharyngeal swallow efficiency (OPSE), and presence of aspiration were measured.

RESULTS:

Four patients dropped out and 20 patients were analyzed (stroke, 13 patients; pneumonia, 3 patients; and others, 4 patients). The mean age was 73.3±11.4 years. There were significant differences before and after the removal of the denture for the OTT. OTT was significantly less after the removal of the denture (8.87 vs. 4.38 seconds, p=0.01). OPSE increased remarkably after the removal of the denture, but without significance (18.24%/sec vs. 25.26%/sec, p=0.05). The OTT and OPSE, while donning a removable denture, were correlated with the masticatory performance (OTT, p=0.04; OPSE, p=0.003) and sensation of oral cavity (OTT, p=0.006; OPSE, p=0.007).

CONCLUSION:

A removable denture may have negative effects on swallowing, especially OTT and OPSE. These affects may be caused by impaired sensation of the oral cavity or masticatory performance induced by the removable denture.

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Surface electrical stimulation in dysphagic parkinson patients: A randomized clinical trial

Baijens LW, Speyer R, Passos VL, Pilz W, van der Kruis J, Haarmans S, Desjardins-Rombouts C.

Laryngoscope. 2013 Apr 17.

Abstract

OBJECTIVES/HYPOTHESIS:

A new treatment for oropharyngeal dysphagia in Parkinson’s disease was evaluated in the present study.

STUDY DESIGN:

Prospective randomized controlled trial.

METHODS:

The study describes the effects of surface electrical stimulation (SES) of the neck (submental region) in dysphagic Parkinson patients using different intensities of electrical current. Quasi-random allocation was performed when assigning patients to treatment groups. Three groups consisting of dysphagic patients with idiopathic Parkinson’s disease (N = 90) received daily treatment for 15 days with periods of no treatment during the weekend. All three received traditional logopedic dysphagia treatment. In addition, two groups received SES, either motor-level or sensory-level stimulation. A standardized measurement protocol, including fiber optic endoscopic evaluation of swallowing (FEES) and videofluoroscopy of swallowing (VFS), was performed before and after therapy. A team of experienced raters was blinded to the treatment group and to the moment of measurement. Intrarater and interrater reliability were calculated.

RESULTS:

Using proportional odds models (POMs), some of the visuoperceptual ordinal outcome variables showed significant improvement in all groups following treatment. Following 15 days of SES of the submental region, few significant effects were found, suggesting a therapy effect of traditional logopedic dysphagia treatment without any additional influence of SES.

CONCLUSIONS:

On the grounds of this study, it is concluded that further research is needed on the exact mechanism of SES and its effects on the neural pathways involved in swallowing.

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Transcutaneous neuromuscular electrical stimulation can improve swallowing function in patients with dysphagia caused by non-stroke diseases: a meta-analysis

Tan C, Liu Y, Li W, Liu J, Chen L.

J Oral Rehabil. 2013 Apr 23.

Abstract

There is still debate over whether the effect of transcutaneous neuromuscular electrical stimulation (NMES) in dysphagia rehabilitation is superior to traditional therapy (TT). The purpose of this meta-analysis was to assess the overall efficacy by comparing the two treatment protocols. Published medical studies in the English language were obtained by comprehensive searches of the Medline, Cochrane and EMBASE databases from January 1966 to December 2011. Studies that compared the efficacy of treatment and clinical outcomes of NMES versus TT in dysphagia rehabilitation were assessed. Two reviewers independently performed data extraction. Data assessing swallowing function improvement were extracted as scores on the Swallowing Function Scale as the change from baseline (change scores). Seven studies were eligible for inclusion, including 291 patients, 175 of whom received NMES and 116 of whom received TT. Of the seven studies, there were two randomised controlled trials, one multicentre randomised controlled trial and four clinical controlled trials. The change scores on the Swallowing Function Scale of patients with dysphagia treated with NMES were significantly higher compared with patients treated with TT [standardised mean difference (SMD) = 0·77, 95% confidence interval (CI): 0·13 to 1·41, P = 0·02]. However, subgroup analysis according to aetiology showed that there were no differences between NMES and TT in dysphagia post-stroke (SMD = 0·78, 95% CI: -0·22 to 1·78, P = 0·13, 4 studies, 175 patients). No studies reported complications of NMES. NMES is more effective for treatment of adult dysphagia patients of variable aetiologies than TT. However, in patients with dysphagia post-stroke, the effectiveness was comparable.

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Effect of the Effortful Swallow and the Mendelsohn Maneuver on Tongue Pressure Production against the Hard Palate

Fukuoka T, Ono T, Hori K, Tamine KI, Nozaki S, Shimada K, Yamamoto N, Fukuda Y, Domen K.

Dysphagia. 2013 Apr 11.

Abstract

Although effortful swallow and the Mendelsohn maneuver are commonly used in dysphagia rehabilitation, little is known about their effects on tongue-palate pressure production. The purpose of this study was to investigate the effects of effortful swallow and the Mendelsohn maneuver on tongue pressure production. Fourteen healthy volunteers (10 men, 4 women; age range = 21-41 years) participated. Tongue pressures during dry swallow, water swallow, effortful swallow, and the Mendelsohn maneuver were measured using a sensor sheet system with five measurement points on the hard palate. Sequential order, duration, maximal magnitude, and the integrated value of tongue pressure at each measurement point were compared among the four tasks. Onset of tongue pressure at the posterior-circumferential parts occurred first in the Mendelsohn maneuver; that at the anterior-median part was earlier than at other parts in the effortful swallow. At all measurement points, tongue pressure duration was significantly longer in the Mendelsohn maneuver than in other tasks. Effortful swallow was most effective in increasing tongue pressure. The integrated value of tongue pressure at the posterior-circumferential parts in the Mendelsohn maneuver and at the median parts in the effortful swallow showed a tendency to increase. These results suggest that tongue pressure increases along a wide part of the hard palate in effortful swallow because the anchor of tongue movement is emphasized at the anterior part of the hard palate. The Mendelsohn maneuver provides prolonged and accentuated tongue-palate contact at the posterior-circumferential parts, which might be important for hyoid-laryngeal elevation during swallowing.

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Nutritional status, food intake, and dysphagia in long-term survivors with head and neck cancer treated with chemoradiotherapy: A cross-sectional study

van den Berg MG, Rütten H, Rasmussen-Conrad EL, Knuijt S, Takes RP, van Herpen CM, Wanten GJ, Kaanders JH, Merkx MA.

Head Neck. 2013 Apr 4.

Abstract

BACKGROUND:

The aim of this study was to evaluate nutritional status, food intake, and dysphagia in long-term head and neck cancer survivors.

METHODS:

Thirty-two patients with stage III-IV head and neck cancer treated by chemoradiotherapy were invited to evaluate nutritional status (malnutrition, relative weight loss), food intake (food modification; quality), and dysphagia.

RESULTS:

At a median follow up of 44 months, 6 of 32 patients were at risk for malnutrition. Women (p = .049) and patients with high body mass index before treatment (p = .024) showed more weight loss. None of the 32 patients could eat a “full diet.” Six patients used nutritional supplements/tube feeding. Low dysphagia-related quality of life scores were significantly correlated to increased food modification (r = 0.405; p = .024).

CONCLUSIONS:

Nutritional advice in patients with head and neck cancer is still necessary years after chemoradiation and should focus on nutritional status, food modification, and quality, in accord with recommended food groups. © 2013 Wiley Periodicals, Inc. Head Neck, 2013.

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Evaluation of Dysphagia in Early Stroke Patients by Bedside, Endoscopic, and Electrophysiological Methods

Umay EK, Unlu E, Saylam GK, Cakci A, Korkmaz H.

Dysphagia. 2013 Feb 5

Abstract

We aimed in this study to evaluate dysphagia in early stroke patients using a bedside screening test and flexible fiberoptic endoscopic evaluation of swallowing (FFEES) and electrophysiological evaluation (EE) methods and to compare the effectiveness of these methods. Twenty-four patients who were hospitalized in our clinic within the first 3 months after stroke were included in this study. Patients were evaluated using a bedside screening test [including bedside dysphagia score (BDS), neurological examination dysphagia score (NEDS), and total dysphagia score (TDS)] and FFEES and EE methods. Patients were divided into normal-swallowing and dysphagia groups according to the results of the evaluation methods. Patients with dysphagia as determined by any of these methods were compared to the patients with normal swallowing based on the results of the other two methods. Based on the results of our study, a high BDS was positively correlated with dysphagia identified by FFEES and EE methods. Moreover, the FFEES and EE methods were positively correlated. There was no significant correlation between NEDS and TDS levels and either EE or FFEES method. Bedside screening tests should be used mainly as an initial screening test; then FFEES and EE methods should be combined in patients who show risks. This diagnostic algorithm may provide a practical and fast solution for selected stroke patients.

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